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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Evaluate neurologic status every 8 hr.

Provide a dark, quiet environment.

Administer magnesium sulfate IV.

Ensure that calcium gluconate is readily available.

Assess respiratory status every 4 hr.

Answer and Explanation

Correct Answer : B,C,D

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.

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Correct Answer is D

Explanation

Explanation:

A. Preeclampsia: Preeclampsia is a condition characterized by high blood pressure and signs of damage to other organs, typically occurring after 20 weeks of pregnancy. While preeclampsia is a concern during pregnancy, it is not directly related to abruptio placentae.

B. Puerperal infection: Puerperal infection refers to an infection that occurs after childbirth. Although infections are a concern in the postpartum period, they are not specifically associated with abruptio placentae unless there are additional risk factors or complications.

C. Anaphylactoid syndrome of pregnancy: Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) is a rare but serious condition where amniotic fluid enters the maternal circulation, potentially causing a severe allergic-like reaction. This condition is not directly related to abruptio placentae.

D. Disseminated intravascular coagulation: DIC is a serious condition where the body's clotting mechanisms are abnormally activated, leading to widespread clot formation in small blood vessels. This can lead to bleeding tendencies and the formation of small blood clots throughout the body. DIC can be a complication of abruptio placentae, especially when there is evidence of bleeding such as petechiae and bleeding around the IV access site. Therefore, it is a significant concern in this context.

A. Hypotension B. Polyuria C. Absence of bowel sounds D. Weakened gag reflex E. Hyperthermia

Correct Answer is ["A","C","D","E"]

Explanation

Explanation:

A. Hypotension: Spinal cord injuries, especially cervical injuries, can affect autonomic nervous system function, leading to neurogenic shock and hypotension. The disruption of sympathetic nervous system control over blood vessels can result in vasodilation and a drop in blood pressure.

B. Polyuria: While urinary dysfunction is a common complication of spinal cord injuries, especially with higher-level injuries, polyuria (excessive urine production) is more commonly associated with lower-level spinal cord injuries affecting the sacral segments. Cervical spinal cord injuries are more likely to lead to neurogenic bladder, urinary retention, or incontinence rather than polyuria.

C. Absence of bowel sounds: Spinal cord injuries can affect the gastrointestinal system, leading to a decrease or absence of bowel sounds due to impaired bowel motility. This can result in paralytic ileus or constipation.

D. Weakened gag reflex: Spinal cord injuries involving the cervical region can affect the pharyngeal and laryngeal nerves, leading to a weakened gag reflex. This can increase the risk of aspiration and difficulty swallowing.

E. Hyperthermia: Spinal cord injuries can disrupt thermoregulation, leading to difficulties in temperature control. Clients with cervical spinal cord injuries may be at risk of hyperthermia due to impaired sweating and heat dissipation mechanisms.

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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

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Explanation

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